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Can Tanzania’s malaria control strategy profit from private drug sellers?

Many African countries are adopting malaria control policies based on artemisinin-containing combination treatment (ACT). What role can private sector drug sellers play? Research in Ikwiriri in Tanzania’s Coast Region shows that specialist drug stores could be key to expanding coverage of malaria treatment.

Malaria control in Tanzania relies on prompt, effective treatment of malaria among children under five. Specialist drug stores could be useful for expanding access to these drugs because they:

often operate in rural centres lacking pharmacies

sell medicines not available at general shops

have staff members with some medical training

are fewer in number and more stable than general stores.

But there are worries about safety and the potential for drug resistance if new ACTs are used unsupervised. To examine the potential role of these shops, researchers from the Ifakara Health Research and Development Centre, Tanzania observed 2,466 client visits to all ten drug stores in Ikwiriri. One in five visits were by or on behalf of people ill with fever or malaria. Of these, 293 were local residents who were interviewed, examined by a clinical officer and given a blood test for malaria.

Clinicians diagnosed malaria in 64 percent – by far the most common diagnosis, followed by acute respiratory infections, anaemia and gastroenteritis.

Malaria parasites were found in blood from a quarter of patients, double the level in the local population but similar to the proportion among people with fever visiting health facilities.

There was a mismatch between clinical and laboratory diagnoses of malaria, especially for people over five years old.

The drug store was the first source of care for nearly three quarters of the customers. Only ten percent had already contacted a formal health facility.

Even in Ikwiriri, where health facilities have improved and highly effective ACTs are available free of charge, many people choose to visit drug stores for malaria treatment. So engaging drug sellers might be essential when introducing ACTs. The Tanzania Food and Drug Authority intends to replace drug stores with Accredited Drug Dispensing Outlets (ADDO), which will receive training, supervision and access to quality-assured products, including some prescription-only medicines, and will meet minimum standards. They could provide an opportunity for expanding access to affordable effective malaria treatment. To maximise the benefit from this, the researchers recommend:

improving malaria diagnosis to reduce the over-diagnosis common with clinical assessment alone

encouraging the sale of suitable doses of effective anti-malarial treatments at specialist drug stores, in place of or in addition to anti-fever drugs

training ADDO staff to avoid potentially harmful practices, such as the inappropriate use of antibiotics and the sale of single drug therapies for malaria

enhancing the appropriate availability of antibiotics for childhood pneumonia

committing substantial resources to rolling out the ADDO scheme nationwide.